Put on the Coffee – I'm Back in School!

Nothing major, just one of those continuing education courses that are recommended from time to time. The kind that helps to keep the aging gray matter somewhat supple and active. This one covers palliative care and the elderly. A perfect topic for me given I'm very fond of the elderly, and because of the work I do, I already know a bit about palliative care. I also hope this course will improve my communication skills when approached by patients and families who want to discuss this topic.

You see, I'm one of those people who tears up at the slightest hint of emotion. The one whose kids roll their eyes in disgust when watching a movie with me. It seems even the comedies bring on my tears. You can just imagine how ineffective I am when talking to patients about end-of-life care.

So, I thought this would be good for me. Maybe it would give me some tools with which to start those difficult conversations. Best of all, it was online -- no tearing up in class. A good online course on a topic I know: This will be easy!

Or so I thought.

The first question in the first section on the first day was posted:

When should palliative care be initiated?

Well, darn it all anyway! I didn't even know the answer to the first question on the first day!

I thought I knew the answer that was expected but refused to write it down. Not so fast, I thought. This is not a cut and dry answer, this is a "well, it all depends" answer, and if you know me, you know that many of my answers are "well, it all depends" answers. Healthcare is a minefield of deviations from the norm. There is no one-size-fits-all solution.

I determined from slide one to 10 of the online presentation that palliative care should be initiated based on what the patient requests. I've seen a few situations where that did not happen and at least one situation where I'm kind of glad it didn't. Patient requests were not enacted, sometimes because of family and sometimes because of the monolithic medical machine that takes a long time to come to a grinding halt even after decisions have been made.

Take, for example, an 87-year-old patient with relapsed acute leukemia and a systemic fungal infection not responding to antifungals. She told me that she wanted to go to the palliative care unit but her family said no, they wanted everything done, and so she was admitted to ICU and died several weeks later. In this instance, I agreed with the content of the presentation. If we had initiated palliative care as soon as the patient had requested it and gotten her to an appropriate unit while she could still be the decision maker, she may have died in a manner in keeping with her wishes.

I also cared for a patient with acute lymphoblastic leukemia who said he didn't want any further treatment. Trouble was, he was only 18 years old and no one else was comfortable with his decision. Questions and explanations were deferred to his parents. He begrudgingly continued receiving his weekly treatments and as far as I know is alive and well.

In the first case, we desperately wanted to provide palliative care but were too slow in initiating. In the second case, we didn't initiate it but should have investigated further as to why the patient was so fed up with treatment, instead of deferring to his parents when we became uncomfortable with his decisions.

In both cases, prompt action in the form of interviewing, support, and intervention would have been a much better course of action. The appropriateness of initiating palliative care would have/could have been better determined through comprehensive and timely assessment.

I posted my "it all depends" response and logged in for our first weekly Webinar. The instructor introduced himself and started the discussion.

"When should palliative care be initiated?" he asked.

"It depends on the circumstances," he answered in response to his own question, going on to give a thorough explanation, much in line with my own understanding.

Ha! I knew it all along. I was so proud of myself! And then he posed a second question.

"Who should initiate the palliative care discussion?"

Darn! It's a good thing I put on that coffee.